Instrument set for laparoscopic hysterectomy

ABSTRACT

The invention relates to an instrument set for laparoscopic vaginal hysterectomy which comprises a uterine rotator comprising a rod with a uterine end for insertion into the uterus and a control end, and with at least one wing moveable in and out of the uterine end which in a folded-out position makes contact with the inner wall of the uterus and which is connected via coupling means to a control member located at the control end, wherein the rod is preferably provided with two wings, and more preferably the rod is provided with a hinge, and with optionally at least one artery forceps provided with a handle and mutually reciprocating jaws.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention relates to an instrument set for laparoscopichysterectomy, including laparoscope-assisted sub-total and totalhysterectomy, and to a uterine rotator and an artery forceps therefor.

Hysterectomy is one of the surgical operations most frequently performedon women. On average the uterus is removed in one of three women.

SUMMARY OF THE INVENTION

Abdominal hysterectomy is generally performed in particular when theuterine volume is large, when extensive pelvic adhesions are present orexpected, and when other pathology such as ovarian cysts, extensiveendometriosis or cancer are present.

Vaginal hysterectomy has the advantage relative to abdominalhysterectomy of a lower post-operative morbidity and the absence ofabdominal scars.

Endoscopic Surgery has been employed more and more in recent years dueto technical developments in the area of video-endoscopy and in the areaof lasers as bloodless, precision cutting instruments in addition topersufflation techniques, such as described in EP-A-0 350 499.

Laparoscopic hysterectomy has already been described by Reich et al., J.Gynaecol. Surg., 1989, 5, p. 213-216.

A frequently occurring problem, especially with a larger uterus, is thatduring the operation the uterus rotates spontaneously whereby theoperation becomes more difficult. Problems can occur particularly at themost crucial moment of the operation, when the uterine artery isligated. Moreover it can be necessary in the case of a myomatous uterusto rotate the uterus in order to expose the broad ligament and theuterine artery.

In order to facilitate laparoscopic vaginal hysterectomy, to shorten theoperation time and to increase the percentage of successful operativeprocedures the present invention provides an instrument set. Theinstrument set for laparoscopic vaginal hysterectomy according to theinvention is characterized in that it comprises a uterine rotatorcomprising a rod with a uterine end for insertion into the uterus and acontrol end, and with at least one wing movable in and out of theuterine end which in the folded-out position makes contact with theinner wall of the uterus and which connected via coupling means to acontrol member located at the control end. It is thus possible with theuterine rotator to fix the uterus and rotate it in controlled mannerwhereby the necessary surgical procedures viewed with a laparoscope canbe optimally performed.

Fixed and controlled rotation of the uterus is further improved if morepreferably the rod is provided with two wings which in that case arepreferably movable diametrically relative to each other and in and outof the uterine end of the rod.

In order to provide a uterine rotator combining good fixed andcontrolled rotation of the uterus with a construction which can beprepared well in pro-operative instrument treatments such assterilization and the like, each wing preferably comprises two wingportions connected for mutual rotation, whereof a first wing portion isrotatably connected to a rod tip and whereof the second wing portion isconnected to the coupling means. When more preferably in folded-inposition the first wing portions are enclosed by the second wingportions the advantage is achieved that a smaller displacement of thecoupling means is necessary for folding out the wings.

If in further preference in folded-out position an angle smaller than180° and greater than 90° is enclosed between both adjoining second wingportions, both second wing portions lie in reflex position inside bothfirst wing portions in the folded-out position, thereby the second wingportions or their coupling to the coupling means do not touch the fundusof the uterus, whereby damage or perforation is avoided.

Optimal insertion of the uterine rotator into the uterus is obtainedwhen in a folded-in position the wing more preferably lies envelopedwithin a rod. It is recommended for this purpose that the rod isprovided with a recess for receiving a folded-in wing. For optimalinsertion of the uterine end it is necessary for this purpose that infolded-in position the uterine end has a round, for instance oval andcircular, shape in cross section.

According to a preferred embodiment the coupling means comprise acoupling element received in the hollow rod. According to a firstembodiment the coupling element is a slide strip, according to anotherembodiment the coupling element is a threaded strip. For goodpositioning of the uterus into for example anteversion, even when thepatient inadvertently lies too high on the operating table, it isrecommended that the rod of the uterine rotator be curved in shape

The rod is further preferably provided with at least one hinge wherebythe uterine end can pivot an the front part of the uterus can be placedin front of the endoscope, If in further preference the hinge is locatedat a distance from the tip of the uterine end such that the pivot pointlies at the height of the cervix of the uterus, parts located forwardlyof the uterus can, by both retroflexion and anterioflexion, be optimallyviewed with the endoscope and become accessible to surgical instruments.The pivoting movement can be performed transversely of as well as in theplane of the wing or wings and the coupling means, including thecoupling element. If however the pivoting movement is followed by arotation movement, a pivoting movement in the plane of the wing or wingsand the coupling means takes preference from the point of view ofsurgical technique.

For optimal positioning of the uterus for the endoscope and surgicalinstruments, it is further recommended that the uterine end be connectedrotatably via the rotation means to the control end. The advantage beingthat through a combination of retroflexion or anterioflexion androtation through about 90°, the lateral uterine blood vessels can beplaced in a posterior or anterior position, whereby the laparoscopichysterectomy is facilitated considerably. The secondary openings in theabdominal wall for the instruments can moreover be arranged at a lowerlevel, for instance below the so-called bikini line, whereby thissurgical approach provides a considerable aesthetic advantage.

Instead of making use of a pivoting and rotation movement, it is alsopossible to use two pivoting movements directed transversely of eachother.

For an easy dissection of the cervix and the uterine artery, it isrecommended that a fornix presentor be guided along the rod of theuterine rotator.

The greatest problem in laparoscopic vaginal hysterectomy is bleedingfrom the uterine artery. Under laparoscopic control, however, it is safeand easy to clamp the uterine artery along the vaginal side wherebybleeding can be avoided. For this purpose the invention provides for theinstrument set at least one pair of artery forceps provided with ahandle and mutually reciprocating jaws which is inserted via the vaginalvault. The jaws are for example 1-3 cm long. The shaft of the arteryforceps is preferably curved. The artery forceps according to theinvention can thus be used in combination with the uterine rotator andcan remain in place when the uterus is removed. An optimal pair ofartery forceps is obtained if each of the jaws pivots around one of thehinge elements lying at a mutual distance.

The present invention further relates to the uterine rotator asdescribed above, and to the artery forceps as described above,

Other features of the instrument set for laparoscopic vaginalhysterectomy, in addition to the hysterectomy according to theinvention, will be further described hereinafter in the light of anumber of non-limiting embodiments and the operative technique, whereinreference is made to the annexed drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a perspective view, partially broken away of an embodiment ofthe uterine rotator of the instrument set according to the invention;

FIG. 2 is a side view of the invention shown in FIG. 1; as seen alongarrow II.

FIG. 3 is a top view of the invention shown in FIG. 2; as seen alongarrow III.

FIG. 4 is a perspective view, partially broken away, of an embodiment ofthe uterine rotator which has a single wing;

FIG. 5 is a perspective view, partially broken away, of the end of theuterine rotator shown in FIG. 4;

FIG. 6 is a partially broken away perspective view of a pair of arteryforceps for the instrument set according to the invention;

FIG. 7 is an enlarged end view of a variation of the artery forcepsshown in FIG. 6;

FIG. 8 is a perspective view, partially broken away, of an embodiment ofthe uterine rotator which has two wings;

FIG. 9 is a section taken along lines IX--IX in FIG. 8.

FIG. 10 is a schematic view of an operative technique for laparoscopicvaginal hysterectomy wherein the instrument set according to theinvention is applied;

FIG. 11 is a side view showing a second operative technique forlaparoscopic vaginal hysterectomy with a uterine rotator as according toFIGS. 8 and 9;

FIG. 12 is a top view showing a second operative technique forlaparoscopic vaginal hysterectomy with the uterine rotator shown inFIGS. 8 and 9;

FIG. 13 is a side view, similar to FIG. 11, showing the uterine rotatorrotating a uterus;

FIG. 14 is a side view, similar to FIGS. 11 and 13, showing aretroflexion-rotation approach in accordance with the operativetechniques according to the invention;

FIG. 15 is a side view, similar to FIGS. 11 and 13, showing ananterioflexion-rotation approach in accordance with the operativetechniques according to the invention;

FIG. 16 is a view corresponding with FIG. 11 of another uterine rotator.

FIG. 17 is a side view corresponding with FIG. 12 of another uterinerotator.

DESCRIPTION OF THE PREFERRED EMBODIMENTS

FIG. 1 shows an instrument set 1 according to the invention forlaparoscopic vaginal hysterectomy. It is a uterine rotator 2 whichcomprises a hollow rod 3 with a uterine end 4 for insertion into theuterus and a control end 5. The uterine rotator 2 further comprises twowings 6 and 7 outwardly movable diametrically in relation to each other.Each wing 6 and 7 comprises a first wing portion 8 that pivotallyconnected to a rod tip 10, and a second wing portion 9 which on one sideis pivotally connected to the first win portion 8 and on the other sidevia a hinge piece 11 to coupling means comprised of a flexible couplingelement 12 and guided in the hollow rod, which coupling element 12 hasthe form of a threaded strip, for which purpose the free end 13 isprovided with a thread 14 onto which a nut 15 is rotated and supportedon the hollow rod 3. Using resetting means (not shown) the couplingelement 12 is pressed to a position in which the wings 6 and 7 arefolded inward. In inward folded position the uterine end 4 has a roundcross section.

The hollow rod 3 is provided with a hinge 53 which can be actuated witha pivot rod 54 which is guided in the hollow rod 3 and ends in a controlmember 55 slidably guided in a slotted hole 56. The uterine end 4 can,as shown in FIG. 2, thus be pivoted downward through up to 70°,preferably through more than about 30°, whereby the ventral side of theuterus can be oriented toward the stationary endoscope 51 as shown inFIG. 10. For the sake of clarity FIG. 3 likewise shows the rotator 2 intop view.

FIG. 4 shows another instrument set 16 according to the invention whichcomprises a uterine rotator 17 which is provided with only one wing 18which has substantially the same construction as the wings 6 and 7 ofthe rotator of FIG. 1. The uterine end 4 of the uterine rotator 17 isprovided with an elongated recess 19 in which the folded-in wing 18(drawn with continuous lines) can be received inside the imaginaryenvelope of the sectionally round rod 20. The wing 18 comprises a firstwing portion 21 connected to the rod tip 23 via a hinge 22 situated inthe recess 19. The other wing portion 24 is pivotally connected to aslide strip 25 guided in the hollow rod. Inward and outward folding ofthe wing 18 takes place by moving the slide strip 25 using a handle 26,which is guided in a recess 27, in the control end 5 which is furtherprovided with a second handle 28.

FIG. 5 shows an instrument set 29 according to the invention whichcomprises a uterine rotator 30 with a single wing 31, the constructionof which substantially corresponds with the wing 18 of FIG. 2. The wingportion 21 is however pivotally connected to a fork-like uterine end 52and a slide strip 32 is guided in a guide path 34 arranged in a solidrod 33.

As is show in FIGS. 1, 4 and 5, the uterine rotators 2, 17 and 30 arepreferably curved. The wings moreover each have a shape which enablegood and certain contact with the uterine inner wall without causinggreat damage.

FIG. 6 shows a pair of artery forceps 35 for an instrument set accordingto the invention. The artery forceps 35 have a curved hollow shaft 36 inwhich a rod 38 is guided and controllable with finger grips 37. The rod38 is coupled to both mutually reciprocating jaws 39 and 40 via thelinks 41 and 42 respectively. The jaws 39 and 40 are urged towards eachother using a spring 43.

FIG. 7 shows another pair of artery forceps 44 according to theinvention wherein the jaws 45 and 46 are movable with a rod 47 of whicha pin 48 is received in slotted holes 49 and 50 respectively arranged inthe angular jaws 45 and 46.

FIGS. 8 and 9 show another uterine rotator 55 according to the inventionwhich likewise comprises a uterine end 56 for insertion into the uterushaving two wings 57 and 58 which comprise semi-tubular first wingportions 59 and 60 which are hingedly connected to semi-tubularrespective second wing portions 61 and 62. The first wing portions 59and 60 are connected via a hinge 63, 64 to the rod 65 and on the otherside via hinges 66, 67 to the second wing portions 61, 62 which areconnected via a hinge 68 to the coupling means comprising a rod 69. Thefirst wing portions 59 and 60 are provided on their free end with a cappart 70, 71.

Rod 65 is constructed from a rear end 72, a central portion 74 connectedthereto via a hinge 73 and a rotatable forward portion 75.

Received coaxially in the hollow rear end 72 are the rod 69 forcontrolling the wings 57 and 58, a rotation tube 76 for causing thefront portion 75 to rotate relative to the central portion 74 and apivot tube 77 for causing the central portion 74 to pivot relative tothe rear portion 72.

The pivot tube 77 comprises on its leading end 78 bevel gear 79 whichco-acts with a bevel gear 80 fixed onto the pivot shaft 81 to which apart 82 of the central portion 74 inserted into the rear end 72 isnon-releasably connected. Due to a rotation of pivot tube 77, the pivotshaft 81 will also rotate via the bevel gear par 79, 80, whereby thecentral portion 74 pivots independently of the rotation pivot tube 77.

Extending through the pivot tube 77, bevel gear 79 and the part 82 isthe flexible rotation tube which is welded to an end wall 83 of thefront portion 75 and which is mounted in the central portion 74 with anannular bearing 84.

It is thus possible from the control end of uterine rotator 55 tocontrol the wings with the rod 69, to perform a rotation of the wingsusing the rotation tube 76 and to perform a pivoting movement of thefront portion 75 via pivot tube 77.

FIG. 10 shows the operative technique with the uterine rotator ofFIG. 1. A video endoscope 51 which is provided with a CO₂ laser (1060sharplan, Laser Industry Limited, Tel Aviv, Israel), coupled to anoperative laparoscope with an internal diameter of at least 7 mm(Stortz, Germany), which is equipped with persufflator (EP-A-0 350 499),whereby a constant pneumoperitoneum is made possible even duringexcessive aspiration, for example as a result of bleeding or after thevagina has been opened, is inserted via the abdominal wall to a positionclose to the uterus. Two or three additional working channels arefurther arranged in the abdomen.

The uterosacrals are then almost but not entirely transected and thedouglas pouch incised up to the vaginal vault. If pelvic endometriosisis present this is first removed. The round ligaments are thencoagulated, transected, the peritoneum is opened and the bladder movedaside. The ligamentum ovarium proprium is transected. Followingdissection of the parametria, the uterine artery is clamped with anartery forceps according to the invention.

Hereafter the procedure continues as for a total or sub-total vaginalhysterectomy. The uterus is then sufficiently mobilized to subsequentlyperform a circular cervical incision even in nulligravidae. Thisautomatically opens the douglas pouch. The uterosacral are grasped. Thelower parametria can be easily grasped and transected. The uterus isthen removed, the peritoneum closed, the parametria and the uterosacralssutured and connected. Finally, the vaginal wall is closed.

FIGS. 11-15 show the operative technique using the uterine rotator asshown in FIGS. 8-10.

According to FIG. 11, the uterine rotator 55 is placed as according toarrow 85 into the uterus with folded-in wings as a cylindrical rod. FIG.12 shows the situation after the wings 57 and 58 are spread by operatingthe rod 69. Here it can be seen that an angle α smaller than 180° butgreater than 90° is enclosed between the second wing portions 61 and 62,so that the second wing portions 61 and 62 and rod 69 can makesubstantially no contact with the fundus of the uterus.

FIGS. 13 and 14 show in combination the retroflexion-rotation approachand FIGS. 13 and 15 show the anterioflexion-rotation approach inaccordance with the operative technique according to the invention.

Through rotation of the rotation tube 76 from the situation shown inFIG. 11 the situation of FIG. 13 is reached, wherein the uterine bloodvessels are now carried from lateral to anterior. In combination with aretroflexion by operating the pivot tube 77 the uterus is carrieddownward and the cervix upward, whereby the uterine artery becomes wellvisible to the endoscope 51 and becomes easily accessible to the arteryforceps 44 and other instruments to be used.

In the anterioflexion according to FIGS. 13 and 15 the uterus is movedupward, whereby for instance large fibromas in posterior location becomeeasily visible to the surgical instruments and the endoscope 51.

FIGS. 16 and 17 show a uterine rotator 86 which is provided with afornix presentor 88 which is slidable along the rod 87 and comprises asleeve coupling 89 with a passage 90 through which passes the rod 87 anda collar 91 which diverges in the direction of the uterus and whichgrips over the cervix. Laparoscopic dissection of the cervix is thussimplified, a also, through localizing of the vaginal walls, isdissection of the uterine artery, namely the ramus vaginalis.

Because the instrument set according to the invention is used forlaparoscopic vaginal hysterectomy, the time duration of the surgicalprocedure can remain limited (up to less than 60 minutes) to the timefor a vaginal or abdominal hysterectomy. Blood loss is moreover greatlyreduced, which is an indirect indication of a safer operation. However,the postoperative morbidity evaluated on the basis of the occurrence ofbowel sounds is considerably lower (vaginal hysterectomy [VH] mean: 1.3days, 25-70th percentile: 1-2 days; abdominal hysterectomy [AH] mean:2.5 days, 25-70th percentile: 2-3 day). The hospital stay is shorter (VH4.5 days as opposed to AH 7.3 days). No post operative complicationshave been noted.

What is claimed is:
 1. An instrument for laparoscopic vaginalhysterectomy, comprising:a uterine rotator including a rod with auterine end for insertion into uterus and a control end; coupling means;a control member; and at least one wing, with the at least one wingmovable from a folded-in position in the uterine end to a folded-outposition in which the at least one wing makes contact with an inner wallof the uterus and with the at least one wing connected by the couplingmeans to the control member located at the control end, and wherein theuterine end of the rod is rotatably connected to the control end of therod by a rotation means.
 2. The instrument as claimed in claim 1,wherein the rod is provided with two wings.
 3. The instrument as claimedin claim 2, wherein the wings are movable outwardly from the roddiametrically in relation to each other.
 4. The instrument as claimed inclaim 2, wherein the rod includes a rod tip and wherein each wingincludes a first wing portion and a second wing portion connected formutual rotation, with the first wing portion rotatably connected to arod tip and with the second wing portion connected to the couplingmeans.
 5. The instrument as claimed in claim 4, wherein the first wingportions are enclosed by the second wing portions in the folded-inposition.
 6. The instrument as claimed in claim 4, wherein adjoiningsecond wing portions are separated from each other by an angle between90° and 180° in the folded-out position.
 7. The instrument as claims inclaim 1, wherein the uterine end of the rod is connected to the controlend of the rod by a plurality of hinges moveable transversely of eachother.
 8. An instrument for laparoscopic vaginal hysterectomy,comprising:a uterine rotator including a rod with a uterine end forinsertion into a uterus and a control end; coupling means; a controlmember; and at least one wing, wherein the at least one wing is movablefrom a folded-in position in the uterine end to a folded-out position inwhich the at least one wing makes contact with an inner wall of theuterus, wherein the at least one wing is connected by the coupling meansto the control member located at the control end and wherein the atleast one wing is substantially enveloped within the rod in thefolded-in position.
 9. The instrument as claimed in claims 8, whereinthe rod is provided with a recess for receiving the at least one wing inthe folded-in position.
 10. An instrument for laparoscopic vaginalhysterectomy, comprising:a uterine rotator including a rod with auterine end for insertion into a uterus and a control end; couplingmeans; a control member; and at least one wing, wherein the at least onewing is movable from a folded-in position in the uterine end to afolded-out position in which the at least one wing makes contact with aninner wall of the uterus, wherein the at least one wing is connected bythe coupling means to the control member located at the control end andwherein the uterine end of the rod has a substantially round shape inthe folded-in position of the at least one wing.
 11. An instrument forlaparoscopic vaginal hysterectomy, comprising:a uterine rotatorincluding a rod with a uterine end for insertion into a uterus and acontrol end; coupling means; a control member; and at least one wing,wherein the at least one wing is movable from a folded-in position inthe uterine end to a folded-out position in which the at least one winmakes contact with an inner wall of the uterus, wherein the at least onewing is connected by the coupling means to the control member located atthe control end and wherein the coupling means include a couplingelement in the rod.
 12. An instrument for laparoscopic vaginalhysterectomy, comprising:a uterine rotator including a rod with auterine end for insertion into a uterus and a control end; couplingmeans; a control member; and at least one wing, wherein the at least onewing is movable from a folded-in position in the uterine end to afolded-out position in which the at least one wing makes contact with aninner wall of the uterus, wherein the at least one wing is connected bythe coupling means to the control member located at the control end andwherein the uterine end of the rod is connected by at least one hinge tothe control end of the rod.
 13. The instrument as claimed in claim 12,wherein the hinge is located at a distance from the uterine end suchthat a pivot point of the rod is located substantially adjacent thecervix of the uterus when the rod is inserted into the uterus.
 14. Theinstrument as claimed in claim 12, wherein the rod is configured suchthat a pivoting movement takes place immediately forward of the at leastone wing.
 15. An instrument for laparoscopic vaginal hysterectomy,comprising:a uterine rotator including a rod with a uterine end forinsertion into a uterus and a control end; coupling means; a controlmember; and at least one win, wherein the at least one wing is movablefrom a folded-in position in the uterine end to a folded-out position inwhich the at least one wing makes contact with an inner wall of theuterus, wherein the at least one win is connected by the coupling meansto the control member located at the control end and wherein the uterinerotator is provided with a for nix presenter guided on the rod.
 16. Aninstrument set for laparoscopic vaginal hysterectomy which comprises:(a) a uterine rotator, including: a rod with a uterine end for insertioninto a uterus and a control end; and at least one wing moveable from afolded-in position in the uterine end to a folded-out position in whichthe at least one wing makes contact with an inner wall of the uterus,wherein the at least one wing is connected by coupling means to acontrol member located at the control end, and (b) a pair of arteryforceps provided with a handle and a plurality of mutually reciprocatingjaws.
 17. The instrument set as claimed in claim 16, wherein the arteryforceps includes a curved shaft.
 18. The instrument set as claimed inclaim 1, wherein each of the jaws pivots on a hinge element lying at amutual distance.